India’s Battle Against the Coronavirus

After spreading to virtually every part of the world and ravaging several large countries including China, the US and most of Western Europe, the Coronavirus Pandemic is now starting to spread rapidly in large emerging markets like India, Brazil, Russia, South Africa and Turkey (amongst others) which are far less equipped to deal with the catastrophic health and economic consequences which have been seen in more developed markets. In recent weeks, India has seen a sharp increase in the number of confirmed cases, which have increased from 113 as of 15th March to over 20,000 as of 21st April and claimed c.650 lives to date . On 24th March (as confirmed cases crossed 500), Prime Minister Modi announced a full national lock-down until mid-April and subsequently extended it until 3rd May, including completely closing all schools, non-essential businesses, and domestic transportation, hoping to avert a massive public health crisis.

Healthspring is one of India’s largest provider of primary healthcare clinics, both retail and corporate, across India and works both with individual patients as well as large corporates to support their health and wellness programs. As the COVID-19 crisis enters its next phase in India, Healthspring has taken the decision to stay open and its doctors are serving people as part of India’s battle against COVID-19 with the aim of keeping them out of hospitals unless that is unavoidable.

Greater Pacific Capital spoke to Kaushik Sen, Healthspring’s CEO about his perspective on India’s battle against the Coronavirus and the role that the country’s large primary healthcare providers need to take in this crisis.

The Interview

India has recently crossed 25,000 confirmed cases of Covid-19 and while the disease does appear to have spread, considering the size of its population, poverty levels and other risk factors, India appears to have been relatively spared thus far from the massive spike in cases and deaths we have seen in Europe and the US. Why do you think this is the case?

There are two broad theories about what is going on India. One is that the actual numbers are much higher, because we have chronically under-tested the population. A substantial number of people believe that to be the case. The second theory, and counter-argument to the first, is that the number of deaths in an aware population is quite hard to disguise (as Iran learned). And if you look at the death rates in India, they have stayed close to what you would expect, which is a 3% rate, which would suggest that though there is under-testing, it may not be significant.

There are a lot of unproven theories “Hopefully we will not see a full-blown epidemic in India; because the really worrying thing for most of us in the public and private health space in India is that these numbers are just a lull before the storm.”also of course of why India’s per capita case numbers are so low such as that the virus does not thrive in warmer climates (30-degrees Celsius or higher). If you look at the initial outbreaks, which were in cooler parts of China, Italy and Iran (one of the coolest climates in the Middle East), there was some anecdotal evidence to support this. However, there is also counter-evidence to that, like in Singapore’s recent outbreak. I don’t think we will know the truth until much later.

At this stage, while there are a lot of theories, I think it is too early to speculate, and only time will tell. Hopefully we will not see a full-blown epidemic in India; because the really worrying thing for most of us in the public and private health space in India is that these numbers are just a lull before the storm, so we are all tracking the numbers closely to make sure it is an arithmetical progression rather than an exponential one.

The Indian government moved relatively quickly to lock down the entire country when there were a little over 500 cases and 10 deaths. What is your view on India’s response? Is the lockdown appropriate and will it be sufficient to contain the spread?

I think the lockdown is absolutely required in India and I would expect it to move through May as well . And even when India comes back online, I think there will continue to be significant restrictions, and there should be.“The best case is that the lockdown continues for a while, and that it is accompanied by significant testing and contact tracing, and a very rapid progression in building the “surge” infrastructure that will be required.” I don’t think the lockdown is sufficient on its own though. Two things need to happen for it to be sufficient: firstly, we need to make sure it we ramp up testing; and secondly, the purpose of the lockdown is to flatten the curve, and the healthcare infrastructure is very far from developed countries, which have been swamped. So, the best case is that the lockdown continues for a while, and that it is accompanied by significant testing and contact tracing, and a very rapid progression in building the “surge” infrastructure that will be required to deal with the number of cases. India is simply not in a position to take a large load on the hospital infrastructure, so it is imperative that the lockdown continues, with widespread testing.

You operate one of India’s largest chains of primary healthcare and corporate clinics? How have you managed through the lockdown?

We have two parts of our business, and the short-term dynamics are quite different across each. About 2/3rd of our revenue comes from our employer-driven primary care and occupational health, which translates to pan-India corporate health programs for employees, and full-time clinics in an occupational health setup. That part of what we do has stayed steady and even grown, as employee health becomes more important. We see a near-term opportunity here for a) return-to-work testing and protocols, b) tele-health, and c) increased deployment of resources and scaling up of existing programs. In the medium-term, we think this crisis will increases the centrality of healthcare for employers.

The remaining part of our business, retail, has seen significant near-term disruption due to the lock-down, but in the medium-term it should be a positive boost for primary care in general, and us in particular. The challenge will be to weather the coming 2-3 months in as resource-light a way as possible.“We feel from a moral and long-term perspective, we must stay open and help the communities, and do whatever we can to tighten our belts at the corporate level so we can do that, but other private operators may not be able to do the same.” Firstly, we had a big decision to take on whether we stay open or not, because most retail points of private primary care have closed due to the lockdown, and no one is really venturing out for anything that can be deferred. But at the same time, we felt we had a social responsibility to stay open for our communities. COVID-19 is only one of the many health issues going around right now and for people who are chronic sufferers for other reasons or have routine medical needs, we can’t just shut shop. So that was a tough call to take.

It is dangerous out there, and I think most health workers globally are facing this decision about what they should do, what is the right thing for their community, what is the right thing for their immediate families. So, what we decided to do is staff about 60% of our clinics with people who live in close proximity with a single shift rather than a double shift. We are trying to do the best for our employees and also our patients and community by staying open. I think the communities are really grateful that we are there for them through this period, though usage of the actual clinics is very low compared to normal times, about 80% down, which we expected.

The real challenge as a private retail primary care operator, is surviving the next few months. In keeping the clinics open for example, we run fixed cost for rent and doctors’ salaries, but there is very little revenue. We feel from a moral and long-term perspective, we must stay open and help the communities, and do whatever we can to tighten our belts at the corporate level so we can do that, but other private operators may not be able to do the same. In India’s case, where a lot of the health infrastructure is private, we need a vision for how to sustain private players economically through this period. The measures by the central bank to allow deferrals of interest and repayments, for example, was a welcome step.

What have you seen change on the ground over these last few weeks in India? How has the current crisis highlighted the need for better primary healthcare?

In these last few weeks, we have seen a strong elevation of the awareness of the importance of primary and preventive health. For examples over the last 3-4 weeks, we have done significant flu and pneumonia vaccine drives, so people are more conscious that they need to at least avoid getting other flus. We have been talking to people about this for years, but now the awareness has gone up.

At the clinics themselves, the reality is that primary care does not have as direct a role to play in managing Covid as the hospitals. Let me explain. If you are diagnosed with COVID-19 and have mild symptoms, the absolute best thing you can do is stay at home, self-isolate/quarantine, make sure you are not spreading it to other people, make sure you are drinking fluids and taking rest, using paracetamol and normal flu medications; and for the vast majority of people this will be enough. If you are showing signs of severe respiratory distress, then the best thing to do is go to a hospital, get admitted, get access to a ventilator in case you need it, and get the type of tertiary care that can only come from an ICU-type facility. In both these situations, it is unlikely that you will need to walk into a primary care facility. We would love to play a part in oxygen therapy and other more innovative treatments, but the current municipal infrastructure does not permit this.

However primary care providers have a critical indirect role to play. Let me try and explain“We are doing a lot in terms of tele-health, home-calls etc. to help patients avoid the hospitals, both because these are a higher risk environment, and to help lessen the burden on the healthcare system.” what the role should be of primary care providers in three different states. Firstly, say there’s a patient who thinks, “I’m not well, should I get tested for COVID-19?” For these people, we can help identify when they should be tested, screen for the many other forms of flu which are far more common and also for other potential causes. Secondly, say there’s someone who believes they have COVID-19 symptoms or have been exposed. For these people, we will help get them tested, we will help monitor them, we will guide them and their family to stay as isolated as possible. And thirdly, in severe cases, our role and the role of primary care is to guide people to the best hospitals where they can get the best care. So, from an awareness perspective, we are focusing on helping our patients cut through the chatter to understand what they should and should not be doing.

Secondly, the role of primary care givers is to help people manage other ailments like diabetes, hypertension, etc. which require regular care. These are the highest risk group for COVID-19, so we are doing a lot in terms of tele-health, home-calls etc. to help patients avoid the hospitals, both because these are a higher risk environment, and to help lessen the burden on the healthcare system. Ironically, that is exactly our mission statement since our inception and what we have been doing all these years, so it plays to our strengths.

As mentioned, on the employer-driven side of the business, we are seeing a significant increase in our existing clients asking us to scale-up our presence and services, which would be very beneficial for the health of employees.

Given, one of the important things India needs to do in the next few weeks is to rapidly ramp up COVID-19 testing, what role do primary care providers like Healthspring have to play in that?

While our labs are accredited, we do about 95% of tests ourselves, but have historically outsourced the 5% of tests that are infrequent. This falls into that bucket and there are a bunch of large private players that we are working with on this front. We also have a partnership with one of the large global pharmaceutical firms that has developed a test, so we are in a good position to advise on and help facilitate tests. “The bigger problem right now is to prioritise who should be tested and making sure they have easy access to tests. We are helping do that by leveraging our symptom tracker and tele-health infrastructure to identify those who need tests but also screen out those that do not to lower the burden on our healthcare infrastructure.”The best use of our network and our brand to help guide patients when they need to be tested and facilitating these. Everyone who is doing this is short on test kits, so the bigger problem right now is to prioritise who should be tested and making sure they have easy access to tests. We are helping do that by leveraging our symptom tracker and tele-health infrastructure to identify those who need tests but also screen out those that do not to lower the burden on our healthcare infrastructure.

The need to test is not going to go away, in fact it will probably accelerate. We may have second and third waves before there is a vaccine. Our strength is that we are touching a lot of patients who trust us, so private primary care givers can play an important front-end role. For example, eventually when big companies want to get back to work, they may want to have everyone tested to ensure continuity.

It will take some time for India to ramp up to a point that everyone can get tested and we may not get to the South Korea levels perhaps ever. Right now, there is a bit of a shortage of capacity, but that will improve over time. The government also appears to be moving fast on this and opening up. But this will be a long haul, so right now and in the near term, the focus needs to be on properly prioritising the people getting tested.

The economic costs of the lockdowns globally have been severe, and in India’s case we have seen the impact it can have on the impoverished population. Several leaders and people are questioning the need for long lockdowns and weighing options to get the economy back online faster. What do you think the way out of this looks like for India?

Yes, there are people at one extreme who subscribe to the whole ‘herd immunity’ idea or think the economic costs are simply too catastrophic to bear vs. the potential consequences of widespread Covid infections. But I think that ship has sailed a while ago and I don’t think anyone has found it to be a viable alternative in the absence of a vaccine.“I don’t see a scenario where things return to ‘normal’ anytime soon. And even with a vaccine, it is unlikely that it is widely available before the next flu season, so come November, we could see another spike, but hopefully, by then, we will have learned a lot about how to manage Covid clinically, societally and economically..” I think the best thing for all of us to do if we want to get the economy back quickly, is in these next 5-6 weeks (and I’m being optimistic), keep strict lockdowns going and maintain strict social distancing, and use this period to build up the health infrastructure, and as the numbers start coming down and the virus goes from being widespread to contained in discrete pockets, you start to gradually come back to work, but with adequate testing and a continued strict isolation of senior citizens, and you slowly bring sectors back online. Bringing it fully back online is not advisable because then, there is a high likelihood that it goes out of our control again and we re in this lockdown and scrambling mode for the rest of the year.

There are some important rays of hope also. There are some treatments that have shown some promise and while the data is not out there for these to be strongly recommended yet, there’s a lot of experimentation happening. So, let us say we give it a couple of months and (a) the virus numbers have come down to a manageable level and (b) there are clinical treatments that are shown to be effective, then those two things combined with some measure of continued social distancing, testing and tracing is going to be the way to go. I don’t see a scenario where things return to ‘normal’ anytime soon. And even with a vaccine, it is unlikely that it is widely available before the next flu season, so come November, we could see another spike, but hopefully, by then, we will have learned a lot about how to manage Covid clinically, societally and economically.

There are some big long-term positives too. The world has shown it can move in lock step and mobilise to solve big problems. Secondly, we are all working a lot more from home, and learning to ask ourselves if that in-person meeting is necessary or if we should hop on a plane. We are seeing the benefits of that on productivity and the environment, so even if some of this carries over into the post-Covid world, this will be a big positive.

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